NCLEX Exam NCLEX-PN National
Council Licensure
Examination(NCLEX-PN) Version:
5.0 Graded A
Course
NCLEX PN
1. A nurse is caring for a client who suddenly develops shortness of breath after surgery. What
is the nurse's priority action?
A. Encourage coughing and deep breathing.
B. Offer oral fluids.
C. Assess airway, breathing, and oxygen saturation. ✅
D. Notify the dietary department.
Answer: C
Rationale: Airway and breathing are always the highest priorities using the ABC framework.
2. Which client should the nurse assess first?
A. Client with chronic arthritis pain
B. Client requesting a sleeping pill
C. Client with chest pain and diaphoresis ✅
D. Client requesting discharge instructions
Answer: C
Rationale: Chest pain may indicate myocardial infarction and requires immediate assessment.
3. Which vital sign requires immediate intervention?
A. BP 128/78 mm Hg
B. Pulse 76 beats/min
C. Respiratory rate 8 breaths/min ✅
,D. Temperature 37.1°C (98.8°F)
Answer: C
Rationale: Respiratory depression is life-threatening.
4. A client with diabetes becomes confused and diaphoretic. What should the nurse do first?
A. Administer insulin.
B. Check the blood glucose level. ✅
C. Encourage exercise.
D. Restrict fluids.
Answer: B
Rationale: Confusion and diaphoresis suggest hypoglycemia until proven otherwise.
5. Which electrolyte imbalance commonly causes muscle weakness and cardiac
dysrhythmias?
A. Hypercalcemia
B. Hypokalemia ✅
C. Hypernatremia
D. Hypermagnesemia
Answer: B
Rationale: Potassium is essential for neuromuscular and cardiac function.
6. Which client is at greatest risk for falls?
A. Healthy 30-year-old
B. Older adult receiving opioid analgesics ✅
C. Teenager with influenza
D. Adult wearing corrective lenses
,Answer: B
Rationale: Age and opioid use significantly increase fall risk.
7. Which action demonstrates proper hand hygiene?
A. Wash hands for 5 seconds.
B. Wash hands with soap and water for at least 20 seconds when visibly soiled. ✅
C. Wear gloves instead of washing hands.
D. Use hand sanitizer on visibly dirty hands.
Answer: B
Rationale: Soap and water are recommended when hands are visibly contaminated.
8. A client receiving morphine becomes difficult to arouse. Which medication should the
nurse anticipate?
A. Flumazenil
B. Naloxone ✅
C. Protamine sulfate
D. Vitamin K
Answer: B
Rationale: Naloxone reverses opioid-induced respiratory depression.
9. Which finding indicates effective oxygen therapy?
A. Increasing cyanosis
B. Oxygen saturation increasing from 88% to 95% ✅
C. Respiratory rate decreasing to 6 breaths/min
D. Increased confusion
Answer: B
, Rationale: Improved oxygen saturation indicates better oxygenation.
10. A client has an IV infiltrate. What is the nurse's first action?
A. Increase the infusion rate.
B. Stop the infusion immediately. ✅
C. Apply restraints.
D. Continue monitoring.
Answer: B
Rationale: Prevent further tissue damage by stopping the infusion.
11. Which finding is most consistent with dehydration?
A. Bounding pulse
B. Weight gain
C. Dry mucous membranes and decreased urine output ✅
D. Peripheral edema
Answer: C
Rationale: Dehydration decreases body fluid volume.
12. Which client requires airborne precautions?
A. Clostridioides difficile infection
B. Active pulmonary tuberculosis ✅
C. MRSA wound infection
D. Influenza
Answer: B
Rationale: Tuberculosis spreads via airborne droplet nuclei.
Council Licensure
Examination(NCLEX-PN) Version:
5.0 Graded A
Course
NCLEX PN
1. A nurse is caring for a client who suddenly develops shortness of breath after surgery. What
is the nurse's priority action?
A. Encourage coughing and deep breathing.
B. Offer oral fluids.
C. Assess airway, breathing, and oxygen saturation. ✅
D. Notify the dietary department.
Answer: C
Rationale: Airway and breathing are always the highest priorities using the ABC framework.
2. Which client should the nurse assess first?
A. Client with chronic arthritis pain
B. Client requesting a sleeping pill
C. Client with chest pain and diaphoresis ✅
D. Client requesting discharge instructions
Answer: C
Rationale: Chest pain may indicate myocardial infarction and requires immediate assessment.
3. Which vital sign requires immediate intervention?
A. BP 128/78 mm Hg
B. Pulse 76 beats/min
C. Respiratory rate 8 breaths/min ✅
,D. Temperature 37.1°C (98.8°F)
Answer: C
Rationale: Respiratory depression is life-threatening.
4. A client with diabetes becomes confused and diaphoretic. What should the nurse do first?
A. Administer insulin.
B. Check the blood glucose level. ✅
C. Encourage exercise.
D. Restrict fluids.
Answer: B
Rationale: Confusion and diaphoresis suggest hypoglycemia until proven otherwise.
5. Which electrolyte imbalance commonly causes muscle weakness and cardiac
dysrhythmias?
A. Hypercalcemia
B. Hypokalemia ✅
C. Hypernatremia
D. Hypermagnesemia
Answer: B
Rationale: Potassium is essential for neuromuscular and cardiac function.
6. Which client is at greatest risk for falls?
A. Healthy 30-year-old
B. Older adult receiving opioid analgesics ✅
C. Teenager with influenza
D. Adult wearing corrective lenses
,Answer: B
Rationale: Age and opioid use significantly increase fall risk.
7. Which action demonstrates proper hand hygiene?
A. Wash hands for 5 seconds.
B. Wash hands with soap and water for at least 20 seconds when visibly soiled. ✅
C. Wear gloves instead of washing hands.
D. Use hand sanitizer on visibly dirty hands.
Answer: B
Rationale: Soap and water are recommended when hands are visibly contaminated.
8. A client receiving morphine becomes difficult to arouse. Which medication should the
nurse anticipate?
A. Flumazenil
B. Naloxone ✅
C. Protamine sulfate
D. Vitamin K
Answer: B
Rationale: Naloxone reverses opioid-induced respiratory depression.
9. Which finding indicates effective oxygen therapy?
A. Increasing cyanosis
B. Oxygen saturation increasing from 88% to 95% ✅
C. Respiratory rate decreasing to 6 breaths/min
D. Increased confusion
Answer: B
, Rationale: Improved oxygen saturation indicates better oxygenation.
10. A client has an IV infiltrate. What is the nurse's first action?
A. Increase the infusion rate.
B. Stop the infusion immediately. ✅
C. Apply restraints.
D. Continue monitoring.
Answer: B
Rationale: Prevent further tissue damage by stopping the infusion.
11. Which finding is most consistent with dehydration?
A. Bounding pulse
B. Weight gain
C. Dry mucous membranes and decreased urine output ✅
D. Peripheral edema
Answer: C
Rationale: Dehydration decreases body fluid volume.
12. Which client requires airborne precautions?
A. Clostridioides difficile infection
B. Active pulmonary tuberculosis ✅
C. MRSA wound infection
D. Influenza
Answer: B
Rationale: Tuberculosis spreads via airborne droplet nuclei.
